Provider Demographics
NPI:1134328750
Name:OSTROM, MICHAEL WRAY (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WRAY
Last Name:OSTROM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 E WHIDBEY AVE
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-2674
Mailing Address - Country:US
Mailing Address - Phone:360-675-2857
Mailing Address - Fax:360-374-5448
Practice Address - Street 1:950 E WHIDBEY AVE
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-2674
Practice Address - Country:US
Practice Address - Phone:360-675-2857
Practice Address - Fax:360-374-5448
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000039811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7084486Medicaid